Authors urge better prevention strategies to avert future disasters.
David Greenhalgh, UC Davis
The massive conflagration in a daycare center in Mexico in 2009 that resulted in the deaths of 49 young children was the result of a panoply of safety and building code violations and an inadequate number of supervising adults to lead the children to safety, a study by researchers at UC Davis and Shriners Hospitals for Children has found.
The disastrous fire joins the ranks of other infamous blazes and should stimulate changes that might prevent future disasters from occurring, and particularly impel greater safety efforts at schools and daycare centers, the study authors said.
The study was led by David G. Greenhalgh, professor and chief of the burn division in the Department of Surgery in the UC Davis School of Medicine in Sacramento. Greenhalgh also is chief of staff at the Shriners Hospitals for Children–Northern California, Burn Center. The study is published online in the Journal of Burn Care & Research, the journal of the American Burn Association.
“We feel that all fire disasters need to be documented in some manner. If we do not dissect the causes of these tragedies then they are doomed to be repeated,” Greenhalgh said. “Many of the characteristics of this fire disaster have been observed previously. The main issue is that prevention efforts need to be followed.”
The disaster took place in Hermosillo, Sonora, Mexico, on June 5, 2009, in the ABC Daycare. On the day of the fire, an estimated 148 children and six adult caregivers were inside the building. Ultimately, 49 children age 3 or younger died during or following the blaze. Children injured in the fire were sent to hospitals throughout Mexico and to two Shriners Hospitals for Children in the United States, in Cincinnati and Sacramento.
The study authors obtained data about the fire and its aftermath from a website established by the government of Mexico to report the results of its investigation of the disaster. Additional data was derived from reports from the Mexican news media and from interviews by the study’s authors with patients and individuals present at the fire.
Examining the factors that led to the conflagration, the study notes that ABC Daycare was located in a four-complex structure that shared walls with two other businesses. The daycare shared a wall with a document warehouse that was made of cinderblocks without concrete filling. Only the daycare’s walls had drywall, which was supposed to be a two- to three-hour fire retardant wall, but the daycare was out of compliance. The building’s roof was made of tin and was lined inside with polyurethane foam. The daycare rooms’ ceilings were covered with ceiling tiles and a large polyvinyl chloride “circus tent” in a central area.
The fire was determined to have started in the document warehouse adjacent to the daycare, rapidly traveling to the nursery through the wall they shared. It is likely, the study says, that the circus tent ceiling “rapidly flashed over to create an explosive fire.” In addition, fire investigators said that the ceiling tiles also ignited, creating a “rain of fire” that involved many of the rooms near the warehouse, the study says.
Several obstacles impeded rescue attempts. There were three doors into the building, but two were locked with the keys irretrievable. The only open door was through the administrative office. Ultimately, rescuers made holes in the centers’ walls by driving trucks through them at four locations to free the children trapped inside. Twenty-nine children died at the scene, 28 of inhalation injuries and one of burns.
The Mexican government investigation, published in Spanish on a government website, found profound safety lapses at ABC Daycare. There were no smoke detectors, no fire alarms, no fire extinguishers, no emergency exits, no valid license to operate a daycare center, no municipal inspections, no fire marshal inspections and improper building materials. The study notes that these findings prompted a government inspection of another 1,480 daycares throughout Mexico, with similar findings.
Following the blaze, 12 children were transferred to Shriners Hospitals for Children–Northern California. The children’s hospital stays ranged from one to 86 days. The patients required, on average 3.75 surgeries, with one girl requiring nine highly complex operations. Two children required amputations of fingers, and one from Cincinnati required a thorough-knee amputation. Two children died, one in Cincinnati a day after admission and one in Sacramento after 50 days of treatment.
Seven of the children required readmission for various reasons during the first year after their burns, with nine reconstructive procedures performed during the readmissions. The majority of the procedures were hand or facial reconstructive procedures. Most of the children will require further reconstructive surgery “to optimize their functional and cosmetic outcomes,” the study says.
Greenhalgh said that the ABC disaster has all of the characteristics of many previous disasters that have occurred throughout the world — and a burn conflagration involving very young children is particularly tragic.
“Many of the fire laws that we have in the United States are the result of learning the specifics of previous tragedies. While the public may not understand why there are exit signs, multiple doors opening to the outside and other prevention efforts, laws and regular fire inspections have reduced the number of major burns and deaths tremendously,” Greenhalgh said.
“Clearly, these same regulations exist in Mexico but they have not been regularly enforced. We do not wish to criticize the people or government of Mexico but instead, we published our paper to incite changes and prevent such a tragedy from happening again,” he said.
Other study authors are Philip Chang, Pirko Maguina, Soman Sen and Tina L. Palmieri of UC Davis and Shriners Hospitals for Children, and Elena Combs of the Shriners Hospitals for Children.
The UC Davis School of Medicine is among the nation’s leading medical schools, recognized for its research and primary care programs. The school offers fully accredited master’s degree programs in public health and in informatics, and its combined M.D.-Ph.D. program is training the next generation of physician-scientists to conduct high-impact research and translate discoveries into better clinical care. Along with being a recognized leader in medical research, the school is committed to serving underserved communities and advancing rural health. For more information, visit UC Davis School of Medicine at medschool.ucdavis.edu.
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